We investigate under the assumption that it is never "operator error". Root causes can nearly always be uncovered because even if an operator makes a misake, the mistake can be traced back to some other failure.WildBill wrote:I agree with both of your comments and observations, but would like to make some additional comments. I have been involved in reviewing many safety incidents.MechAg94 wrote:THis is definitely true. Most of the time, accidents happen because of a combination of things. Often, most of those things were done all the time with no consequences for years before they all stacked up together to produce the accident.anygunanywhere wrote:The safety philosophy of my employer is that all accidents are preventable. This all encompassing philosophy covers a lot of responsibility from all engineering and operations disciplines.
Even though all accidents are preventable not all accident causes are negligent.
Some causes can and do get attributed to unsafe conditions but the majority are a result of unsafe behaviors.
Most accidents can be traced back to multiple causes and/or behaviors that contribute to the event. In almost all cases, if only one of the unsafe behaviors or conditions had been removed or corrected the accident would never have happened.
For the most part, we as a group are reasonable people and strive to be accident free because our chosen passion can very easily lead to serious injury and death if we do not stay vigilant.
Anygunanywhere
That said, there are things we as gun owners can do to minimize accidents and we need to be as vigilant as possible to adhere to those safety rules.
IMO, the investigation should be focused in determining the root causes of the accident so that they can be eliminated by some type of corrective action so they do not reoccur. The probable that I see is that too many people want to jump to a conclusion and point blame - usually at the operator - the lowest guy on the totem pole. Then they say "Train the operator" and that is the end of it.
The investigation must go beyond the direct cause to get to the root cause. For example "The operator turned the wrong switch" may be the direct cause of an accident, but it is not the root cause. You have to keep asking why did this happen until you dig down deep enough. As both of you stated most accidents happen because of a combination of things going wrong. That is why it is essential to find as many root causes as possible so they can be eliminated. I know I am preaching to the choir, but I hope to give some of the people reading this some more insight.
Anygunanywhere